Provider Demographics
NPI:1306108543
Name:JADED BODY WELLNESS & SPINE INSTITUTE, LLC
Entity type:Organization
Organization Name:JADED BODY WELLNESS & SPINE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CAPRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-631-0600
Mailing Address - Street 1:645 N JESSICA BROOKE CIRCLE, STE C
Mailing Address - Street 2:STE C
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7333
Mailing Address - Country:US
Mailing Address - Phone:907-631-0600
Mailing Address - Fax:907-631-3032
Practice Address - Street 1:645 N JESSICA BROOKE CIRCLE
Practice Address - Street 2:STE C
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7333
Practice Address - Country:US
Practice Address - Phone:907-631-0600
Practice Address - Fax:907-631-3032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT0068Medicaid